Social Skills Part II: Behavior then Mood

I want my clients to begin their experimentation into the social world by making impressions.  In order to do this, they must be out and about.  Often times, individuals I work with do not come in to visit with me until self-esteem has begun to suffer.  As a result, I may also be dealing with some mood difficulties.  My role, provided that we are not dealing with a clinically significant major depressive disorder, is to begin coaching the individual with regard to the behavior preceding the mood.  In other words, my clients often times do not feel like they would like to go to the football game on Friday or feel up to attending the homecoming dance.  This consistently comes up in my social skills groups where at least one child does not want to participate or feel like they need to be a part of the group.  They have yet to experience the behavior of being in the group so how in the world would they know that they won’t like it?  Despite the potential to sustain the current social difficulties, there is usually at least one parent who gives in and allows their child to avoid attending the group.   Progress can never be made when this happens.

Staying home will do nothing more than exacerbate the current feeling (I don’t need to go to a group or be social).  Instead, the behavior must come before the desired feeling.  Specifically, individuals must attend the football game or they must attend the dance before they can begin to truly experience the feeling of improved self-esteem, for example.  Most of my clients, although they object to this initially, return to my office to inform me that although going to the dance or football game was the very last thing that they wanted to do on that particular evening, once they were there it was not so bad and they actually ended up enjoying themselves.  Keep in mind that although I use dances and sports games as examples, the behaviors preceding the mood applies to all ages: going to the playgroup, playground, birthday party, etc.

I think it’s also important to illustrate that we must take the pressure of social skills off of these individuals.  In other words, there is no expectation when we are just getting started with making impressions other than the individual simply must attend events.  That’s it, plain and simple: attend the event or activity.  I don’t care if you talk to anyone.  I don’t care if you make any eye contact with anyone.  We have plenty of time to work on that.  One of the biggest hurdles that I see is getting my clients to leave their home because they often do not feel like it.  This is the time that I remind individuals that the behavior must often precede the mood.

This is important because individuals who are feeling dejected or otherwise depressed in any manner may not have the energy, confidence, or motivation to make that initial leap into the social world.  My response is that continuing to avoid the social world only exacerbates the current difficulties.  I am not asking for these individuals to go out on any particular evening or to attend any particular event and come home with a new friend or social group.  I am simply asking that they be seen in the social environment and thus make an impression.  The behavior preceding the mood is important because these individuals may not feel like being social on any particular evening.  In fact, this often perpetuates the addiction cycle of video games as a self-medicating remedy.  Indeed, they will use video games as means of avoidance or as an excuse for why they won’t attend (“I don’t want to go because I’m really into this game…don’t bother me!”).

Client after client returns to my office to tell me that although they were very upset with me and did not want to go to the school dance or football game they took a risk (with the help of sufficient support and encouragement) and they went.  Although they felt ‘awful’ prior to attending the event, once they were there they realized it wasn’t so bad.  Further, the strategy of simply being in the social environment paid off because there were no pressures to achieve any outcome other than attendance.  I know we would all like to jumpstart this process and in our typical American fashion get to the outcome quicker and without much work.  Unfortunately, it does not work that way when dealing with social interactions.  If you are not prepared to take the preliminary steps you will not be successful.  If you rush this process you will not be successful.  Take your time and be willing to take a risk.  Some discomfort is inevitable before progress can be achieved.

“Progress always involves risk; you can’t steal second base and keep your foot on first.” –Frederick Wilcox

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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‘Tis the Season: Preparing Your Child for the Holidays

No matter the holiday traditions or customs you observe, one thing is for certain: the children will be home for a week or two beginning very soon!  No reason to panic.  After all, adults never experience any stress over the holidays so why should kids?  I tried to effectively demonstrate a tongue-in-cheek tone with that last sentence.  I was testing your electronic social skills.  Okay, back to the topic at hand.  The children will be home for a while and you are becoming anxious that tempers may begin to flare or boredom may ensue.  I offer the following general suggestions to hopefully sustain your holiday cheer throughout the school break.

  • Increase predictability at home.  This involves some scheduling, although flexibility should be allowed.  For teens who need to catch up on some sleep, there should be parameters such as “awake by noon” but no need to be so scheduled (“Be up by nine because I said so!”) that arguments are inevitable .  The more that children know what to expect, the less stress that will result when making transitions.
  • Have a portion of each day scheduled but plan the rest of the time with the child by allowing for their input.  You may need to offer a list of suggestions for them to choose from, but you should not be trying to win the contest for Entertainer of the Year.  thus, it is not your responsibility to ensure that your child is having fun all the time!  It may be useful to have a written or picture schedule for some children.  This is especially helpful when you are resting in the afternoon and your child comes to you to say, “I’m booooored!”  You can calmly refer them to the schedule and add, “I know you will figure out something fun to do from all those options, honey.”
  • Keep an eye on your own stress level as there is a trickle down effect.  As we reunite with family, all of those fun dynamics from childhood tend to surface.  Children generally have fewer demands on them during breaks which is why they tend to do better behaviorally.  If you need a break from your relatives, then don’t over schedule.  Your kids will pick up on your stress and react accordingly.
  • Remember to limit television time.  I know this sounds crazy.  After all it serves as an effective pacifier and most parents will ignore this suggestion.  However, trying to get the child away from the TV after they are allowed unlimited viewing will not likely be met with willingness from the child.  The recommendation for television viewing during the holidays is 1-2 hours each day (which includes other screen time such as computers and video games).  Some children can effectively manage more, other cannot.  Certainly, exceptions can be made for holiday movies, family videos, etc.  The general rule is to keep an eye on the time, though, because school will again be in session and the child will then have to “detox” from all the television viewing as they begin to focus on the “boring” schoolwork again.  Maybe reading a fun book in exchange for some of that TV time might keep the old brain cells fresh and sharp?
  • Whenever possible, prepare the child in advance for holiday visits.  If only someone would prepare you!  It never hurts to discuss who will be there, what will take place (as much as you can anticipate before the first family argument occurs), and how long the visit will last.  Children with sensory issues may need an escape plan that can be determined upon arriving to the party or gathering (or in advance if the location is familiar).  The child can use this “escape” for a set period of time to regulate him/herself and then must return to the gathering.  Bring a familiar item from home if your child is anxious about these visits.  Also, talk to your family members in advance and if your child is shy or anxious, remind them to let the child warm up and not force hug, kisses, etc. upon greeting the child.
  • Finally, prepare the child for transitions.  My colleague, Dr. Rick Solomon, has devised 20 Transition Tricks that he recommends for parents who have a child who cannot shift easily from one activity to another.  His general rule of thumb is to acknowledge the child’s feeling of not wanting to transition but then to begin to prepare them for what awaits.  There are a variety of strategies such as time warnings, use of humor, and bribes-but ultimately the child needs to go where we need them to or there will be a consequence.  Try to avoid these control battles whenever possible, though, and with some scheduling and preparation this will hopefully be a safe and happy holiday for everyone!  If it’s not the “Most Wonderful Time of the Year,” then join the club.  By keeping expectations reasonable and being able to laugh off some of the family dynamics that play themselves out across most households, this may result in the impression of a relaxing and enjoyable holiday!

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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Protecting Self-Esteem Among Children and Teens

This is an area that is important regardless of a child’s developmental history, socioeconomic status, gender, or race.  As parents, we watch as our children are generally so carefree and assured, with the slightest compliments effectively reinforcing their every move.  Then we have to let them go at some point; to go away from the safety and comfort of our homes, and enter into the land of school.  We now don’t have any control over who they will meet or how they will be treated.  We must simply wait and pick up the pieces as we try and put on our best ‘poker face’ listening with angst, guilt, and anger (among other emotions) to our child recount being teased earlier that day.  I used to believe, perhaps hope, that self-esteem was not at risk until the junior high/middle school years, or what I like to call: “the years in which all kids should either hibernate or be allowed to stay home until maturity sets in.”

Unfortunately now I know better.  Self-esteem is at risk the moment a child enters preschool or daycare.  It just looks different.  Kids as young as preschool age can be heard telling each other, ‘I don’t want to be your friend,” or “I don’t like you.”  I recently listened to one of my colleagues recount how when her son was younger he came home one day and told her, “Johnny told me that he didn’t want to be my friend!”  She recalled how she bit her lip and was ready to give him a big hug as he was surely on the verge of tears.  She put her ‘poker face’ on and asked her son, “What did you say?”  Her son responded in a matter-of-face tone, “Who cares!?”

There has to be something to that response.  Some kids are simply born with a suit of armor that can repel these meaningless comments while others are devastated at the very thought of anyone not liking them.  Self-esteem begins to be chipped away each day in school whether a child is having a difficult time with math, or reading, or friendships, or basically anything that the child begins to internalize as making them ‘defective’ or ‘flawed’ in any way.  This is the same reason why the notion of a child being deemed ‘lazy’ by their teacher is ridiculous.  Kids are absolutely devastated when they cannot keep up in class, don’t answer a question correctly, take longer than their peers to complete an assignment or test…the list goes on and on…  You tell me how that is lazy.

So what is self-esteem and how can we help our kids achieve and maintain it?  My favorite definition comes from a pioneer in the field of psychology, William James.  He defined self-esteem with the following equation: Self-Esteem = Success/Pretensions (or Success divided by Pretensions).

Pretensions are viewed as goals, purposes, or aims, whereas Successes constitute the perception of the attainment of those goals.  Thus, we essentially decide in our own minds when we have achieved success based on our own expectations for that success.  When self-esteem begins to suffer is when an individual comes up short in his or her perception of reaching a particular goal, especially when the individual compares his or her achievement of a goal against the achievement of others.   So, for the child who either tells himself (or hears it from his parents) that he must get straight A’s and then gets a ‘B’ in gym class only to be outdone by one of his academic rivals, self-esteem has just taken a ‘hit.’   Whereas the child who really struggles in gym class and has lower expectations but eventually achieves a ‘B’ in the class may have a rise in self-esteem.

The bottom line, which is as important for adults as it is for kids, is that we have to have multiple ‘columns’ or ‘pillars’ of support to our self-esteem.  If we rest all of our esteem on how well we do in school and then do lousy on a test, then we are in trouble.  This is why I strongly encourage kids to pursue a variety of interests beginning in middle school even if they only end up liking a few things.  I don’t expect that they will like everything they try, but having at least a few new interests to add to the old can insulate them down the road if just one of their previous interests does not go well.

Imagine that I, a pediatric psychologist, enter a contest and win the opportunity to throw out the first pitch at a baseball game.  I practice a little so that I don’t embarrass myself on the big day and then the day arrives.  I step up on the mound, try a bit of a wind up, and throw a wild pitch that sends the catcher scrambling and draws jeers from the fans.  It’s all in good fun and I laugh it off.  Why don’t I hang my head and beat myself up about this?  Why hasn’t my self-esteem suffered?  Well, for starters I am not a trained professional pitcher so why should I be expected to throw an accurate pitch from that distance?  But what if I were and I performed the same way?  Then my self-esteem might be in jeopardy because my pretensions are different.

The young boy I discussed earlier comes to mind.  As a psychologist, my reaction to my wild pitch can safely be “who cares?”  There are plenty of other things I do well and my pretensions for throwing the ball well were low.  As a result, not achieving success was okay.  This is exactly why we need to have multiple pillars of support.  If my entire self-concept is tied up in how knowledgeable and helpful I am as a psychologist, and a child comes to see me that I can’t seem to get through to, then I might beat myself up and question my competence.  However, if I go home to my family that night and watch as my daughter runs to greet me and play with me, I am reminded that there is more to me and my self-concept than what I do at work.  Adults as much as kids run into this problem and it gets them into big trouble.  The workaholic father, for example, who is so angry with his family every night because he can never truly be successful at work due to his extremely high pretensions.  His goals are too lofty and as a result he cannot find happiness in other areas…work is his only pillar of esteem and he has little energy left for much else.  Kids need to be reminded multiple times each day of their lives to find successes in what they do and increase the chances of that by doing a variety of different things.  A bad day at school is only devastating when the pretensions of how school should go are set too high.

Often what I worry about with the kids I treat is that they have suffered too many losses of esteem and don’t like the feeling anymore.  As a result, they fall into the cycle of avoidance.  Indeed, in their minds they think: With no attempt there can be no failure; with no failure no humiliation.

So our self-feeling in this world depends entirely on what we back ourselves to be and do. It is determined by the ratio of our actualities to our supposed potentialities; a fraction of which our pretensions are the denominator and the numerator is our success: thus…

Self-Esteem = Success/Pretensions.  Self-esteem is ultimately increased by increasing our successes in life while also decreasing our pretensions.  I would strongly encourage all of us to keep our pretensions realistic and not depend on too much success in any one particular area of our lives.  The more we spread it out, the safer we are or the more intact our self-esteem remains.  Keep your options varied and open and don’t lose sight of what you are good at, even when you have a bad day and one of your columns of support happens to collapse on that particular day.

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.



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Social Skills Part I: ‘Impressions’ and Being ‘Out and About’

night_game

This is the first in an ongoing series I will be presenting on Social Skills.  I spend a significant portion of my clinical practice working with children and teens on social skills.  Many parents are curious about my approach and philosophy on teaching social skills, so I thought I would begin posting my thoughts on the matter (in no specific order).  I will being by discussing ‘impressions’ and the initial need to be seen and not heard.

I often discuss social interactions as similar to advertising impressions.  For example, when businesses buy billboard advertising on the side of highways, they often first collect statistics on how many “impressions” their billboard location has on a particular day.  The advertisers want to know specifically how many individuals will see their advertisement over the course of a day, week, month, or year.

Individuals with social skills difficulties often become dejected and suffer a loss of self-esteem when they make one or perhaps even a handful of attempts at engaging others in a social interaction and these attempts are unsuccessful.  I am often able to use my advertising analogy with my clients who will begin to understand that not every person who drives by the Pepsi billboard on the highway is going to purchase that particular product.

When the available options for friendships is smaller such as in an elementary school, certainly the stakes are higher and each impression that is made must count.  However, I often coach my high school-age clients that they cannot expect to sit in their basement playing video games every weekend and then come into my office wondering why they are not more popular in school.  We often discuss the ‘content and process’ approach to social interactions which can be loosely applied to various junior high school and high school activities.

For example, I may work with individuals who have little interest in sports especially when it comes to participating in them.  However, anyone who has attended high school is well aware of the fact that, especially during the fall and early winter months, the place to be is the local high school football game on Friday night.  When it comes to “impressions” such as those found in advertising, being seen even if not heard is a basic starting block for my clients.

I have to remind these individuals to relax initially and just be there rather than try to initiate interactions with others or practice social skills techniques they may have learned by reading a book or from a counseling session or group.  I am generally opposed to social skills techniques being ‘taught’ because the nature of individuals with social difficulties is to study and memorize something in a rote fashion or linear manner and social interactions are far from rote or linear.  More on that topic in a future posting…

Indeed, although these individuals would love nothing more than to reduce social interactions down into a mathematical formula where there is a very specific path that must be followed in order to reach the appropriate or correct outcome, social interactions are generally not linear or rote, and are instead fluid and contain millions of variables and exponents that might be comparable to the mathematical variable of (Pi).  Thus, I want my clients to begin their experimentation into the social world by making impressions.  In order to do this, they must be out and about.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.  Learn more about his Social Skills groups here.

© 2009 Mark Bowers, Ph.D.

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“Cats Are Autistic Dogs” Part II: Notes on Asperger’s

ASD PuzzleThe response in my office and on the web has been so positive to my previous posting on Asperger’s features, that I thought I would share some more thoughts.  I would also like to thank the people over at CafeMom.com for adding my blog to their impressive Autism/Asperger’s/PDD awareness group.

  • Aspies are usually the offspring of Asperger’s fathers who are socially shy and usually have careers in engineering, computers, accounting, or the math/science fields.  The moms of Aspies tend to be teachers, social worker types who are very outgoing, social, and often Type A or ‘organized’ personalities.
  • Siblings of Aspies tend to be gifted/talented, have ADHD or OCD features, or even have anorexia diagnoses (there is a perfection element somewhere in the gene pool).
  • Group projects in school are one of the biggest difficulties because of the social element.  This is the same reason why Aspies do so well in solitary occupations like computer programming but then begin to struggle when they are promoted to management.  Aspies do not manage people and social interactions well.
  • We don’t give Aspies enough credit for how hard they work during the school day.  They keep it together during school and then ‘fall apart’ or are completely exhausted when they return home.  They work at least three times as hard to keep up with the social environment inherent in the school setting.  REMEMBER: Aspies need to learn both academics and social skills in school while neurotypicals only need to learn academics (the social aspect comes naturally).  Imagine the energy differences between the two groups after the same school day!
  • Aspies in history were found in monasteries or were carpenters, jewelery/watch makers, and explorers.
  • Young Aspies may look like children but they act like adults.  Their social difficulties attract bullies as well as female peers who are the ‘caregiver’ type.
  • We usually make the error of telling Aspies, “I shouldn’t have to tell you…” when in fact we have to instruct them every step of the way when it comes to social interactions.  Remember to use logic, not punishment.
  • Aspies value intelligence more than anything.
  • When trying to get an Aspie to stop a behavior, use their desire for intellect to your advantage.  For example, if your child has difficulty sharing, try telling him, “Smart people share.”  Sometimes Aspies will hear foul language and repeat it without knowing the meaning behind it.  Telling the child, “Smart people don’t use those words” will usually do the trick.  The other technique is to exaggerate your response to the word such as holding your hands over your ears if your child repeats something inappropriate and yelling “Ouch!  That hurts my ears!”
  • Aspies often tune out during class lectures or social situations because their thought is, “If this is not one of my strong interests then why should I involve myself with it?”
  • The rigidity in thinking inherent among Aspies also creates difficulty converting thoughts and emotions into speech (communicating feelings) as well as getting thoughts from one’s head onto paper for a report in school, for example.
  • As the chronological age of the Aspie increases, the emotional, maturational, and social development stays at a younger level.  Younger neurotypical siblings will eventually surpass their older sibs in social and emotional development.
  • Aspies look at the action, not at the motives of the action.  So when they are ‘hit’ by a peer who was giving them a joking tap on the shoulder, they tend to retaliate because their thinking says, “He hit me, I ‘m going to hit him back!”  Guess who ends up in the principal’s office?
  • The nature and severity of Aspie symptoms vary dramatically from day-to-day.  This is a ‘swiss-cheese’ developmental presentation with no clear, consistent pattern.  This not only complicates the diagnosis, but schools often try to argue that a child does not have Asperger’s because of having ‘good’ days at times.  They also say things like ‘he is so smart’ or ‘he makes good eye contact.’  Parents often know that a particular day is a ‘good one’ versus a full-on ‘Aspie day’.  Also, full moons actually seem to have an effect on severity of symptoms!
  • Aspies misinterpret behaviors.  An adult may raise their voice to be heard in a crowded room or to make a point.  An Aspie will always see shouting as anger and thus the reasons for raising one’s voice must be explored in depth.
  • If your Aspie child is upset, consider the following:
  • People are confusing to Aspies.  Thus, you want to eliminate the social context when the child is upset.  This is not the time for a face-to-face chat…face the wall if you need to!  (Dr. Mark sits to the side of the child and speaks in the same direction the child is looking..don’t worry about eye contact at this moment!).
  • Tell the child, “I don’t need to know what happened right now.”
  • Keep emotionally calm yourself.  Adding your own emotion at this time is like pouring gas on a fire.  Be sure to tell the child, “I’m not upset with you.”
  • Begin helping the child to calm down by suggesting closing their eyes, deep breathing, and other relaxation strategies.
  • Compliment the child and give them something to look forward to.  “I think you handled this situation with intelligence and I know that the next time you are upset you will do another good job.  What do you say we go look at your book of the planets?!”
  • Children with Asperger’s should be allowed to complete a project on emotions/social skills at least one hour each week while in school beginning in Kindergarten through 12 years of age.  Schools need to do a better job of teaching these children the Hidden Curriculum.
  • For every hour an Aspie is social, they need about an hour to unwind and decompress.  Thus, there is not enough time to unwind after a full school day.  Ever wonder why the stress level is so high during the school week?  How about the trouble getting homework completed?

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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Autism Diagnosis: Now What?

Many families that come to my office for an appointment with an existing diagnosis tell me that they received a “general autism spectrum diagnosis” and the clinician did not really discuss treatment options beyond the diagnosis.  If this is actually the case, then it is frustrating to hear.  I can only imagine the frustration that these families must be experiencing: so many questions and so few answers.  Indeed, I often spend my time calming parents down and gaining their trust as an advocate and ally for them who is ready to give very specific suggestions based on their child’s specific developmental profile.  For the families that do not have the opportunity to be seen in our clinic or who are going to be making an appointment in the near future, I thought I would share what the science says you should do following your child’s autism diagnosis.  I will reserve my thoughts on alternative treatments that are not based on the science for a  future blog posting.  For now, I prefer to guide my families toward treatments that science supports as effective.  So here are the main starting points for treatment following autism diagnosis that are based on the National Science Council Research Report:

1)      20-25 hours per week of intervention

2)      With a 1:1 or 1:2 teacher to child ratio

3)      That is engaging

4)      Has a strategic direction

5)      And starts early (Between the ages of 18 months to 6 years)

Typically these interventions (which count toward the 20-25 hours per week) include:

Two highly recommended websites:

1)      Your Child: Autism Spectrum

2)      P.L.A.Y. Project

Another nice resource for what can be done during the First 100 Days following diagnosis can be found here.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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“Cats are Autistic Dogs”: Notes on Asperger’s

The title of this posting is taken from Dr. Tony Attwood’s discussion on Asperger’s last week.   As indicated in a previous posting, I had the opportunity, or shall I say privilege, to spend an entire day hearing Tony speak his thoughts on Autism and more specifically Asperger’s Syndrome.  I thought I would share some talking points as they relate to Asperger’s for those of you who were unable to attend.  Please note that the term ‘Aspie’ is not derogatory and is instead embraced by many individuals with Asperger’s when describing themselves.

  • Aspies use intellect, not intuition.  Only logic works when trying to discipline…punishment does not work!
  • Handwriting is a huge problem for Aspies, but handwriting is a 19th Century skill.  Teach kids to type!
  • Aspies may tune out because if it is not one of their key interests, then why learn it?
  • Preoccupation with specific topics of interest produces euphoria and enjoyment that Aspies cannot obtain otherwise.
  • Girls are able to hide their symptoms so well that diagnosis may be missed or delayed as much as 10 years.  Girls will often escape into imagination, fantasy, and fiction and “pretend to be normal.”
  • Asperger’s includes all neurotypical characteristics magnified to the most extreme degree.
  • There is a compulsion to complete tasks that Aspies experience which makes transitions difficult.
  • Aspies generally DON’T learn from mistakes..and they don’t naturally know what else to do when faced with a challenging social situation.
  • Anxiety begins to be expressed in the form of avoidant or controlling behaviors as a means of coping with uncomfortable feelings.
  • When emotions run high, there are three ways Aspies try to repair them: 1) Aggression/Rage, 2) Isolation, and 3) Avoidance via heightened special interests (e.g., video games).
  • Sadness and anxiety are expressed by Aspies in the form of anger, especially in school when Aspies are not allowed to use one of the above three ways of coping/repairing heightened emotions.
  • For Aspies, anger is the ‘acceptable’ way to express sadness.  It also allows the individual to get the uncomfortable rise in emotional feelings over with by exploding and then feeling better quickly as if nothing ever happened.
  • Top three trigger words guaranteed to get a rise out of Aspies: 1) No, 2) Wait, and 3) Change
  • An Aspies’ need for affection can fit inside a cup.  A neurotypical’s need for affection can fit inside a bucket.
  • Aspies generally have an intense dislike for public praise.
  • ‘Cats are Autistic Dogs’ is an observation by Attwood meant to illustrate the differences in social abilities/interests of the two animals.
  • For More on this Topic, view Part II of this post here.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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Autism and OCD in Children

hand_washingAutism Spectrum Disorders (ASDs) and Obsessive-Compulsive Disorder (OCD) can and do occur at the same time.  OCD is a specific diagnosis under a larger umbrella of anxiety.  Children with OCD experience unwanted and intrusive thoughts that they can’t seem to get out of their heads (obsessions), often compelling them to repeatedly perform ritualistic behaviors and routines (compulsions) to try and ease their anxiety.  Children with ASD generally have repetitive, perseverative thoughts that are intense in nature, much like children with purely OCD symptoms.  The big difference is that children with OCD do not like the experience of having repetitive thoughts and would do anything to get rid of the thoughts (such as washing one’s hands 25 times).  Children with Autism Spectrum diagnoses are not bothered by their repetitive behaviors and thoughts, and instead are usually comforted by them (such as playing with a train in a repetitive fashion for hours at a time).

Anxiety is highly prevalent among children with Autism Spectrum diagnoses (greater than 35% of children experience both).  This is due to a combination of genetics, brain development, and higher levels of stress.  The error that many schools and therapists often make is attributing a child’s anxiety symptoms to his or her Autism diagnosis (i.e., “The only way to really reduce  anxiety and aggression is to treat the Autism.”)  For example, many children are referred into social skills groups when what they really need is help with anxiety that is interfering with their social functioning.  Highly anxious children with OCD may begin to act out behaviorally in school prompting teachers to encourage (some might say ‘coerce’ or ‘force’) parents to begin medicating the behavior.  The concerns here is twofold: 1) the behavior is numbed with medication and the root anxiety is never truly addressed (i.e., stop the medication and everything returns to the way it was), and 2) the school may begin to implement safety nets such as increased para support to keep the behaviors from occurring while again failing to adequately address the underlying anxiety symptoms.

The question often asked is, “Can you really treat a child who has both an autism spectrum diagnosis and OCD?”  The answer is “yes” and new research is beginning to show that there are some exciting recent behavioral treatments out there for these children.  Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for anxiety that has been established by the American Psychological Association as effective for children.  A recent study of CBT for neurotypical children with anxiety (Wood et al., found):

  • Childrens’ school performance improved & they attended school more regularly
  • Children had more friends & better quality friendships
  • Children got along better with family members
  • Children had higher self-esteem

The authors of that study have adapted the neurotypical CBT protocol for children with autism spectrum and are finding some promising results.   In general the results suggest that the authors’ adaptations of the pre-existing CBT manual can be effective for treating anxiety such as OCD in children with autism (research article link).  This treatment manual is available to practitioners and families, a sample of which can be viewed here.   Thus, there is hope for effective anxiety treatment for your child who also has an autism spectrum diagnosis.  It is highly recommended that you seek out services from a pediatric specialist who has training and experience treating children with co-occurring anxiety and autism spectrum diagnoses.

On a personal note and aside, I will be spending tomorrow with noted Asperger’s guru Dr. Tony Attwood  so stay tuned for a blog later this week where I hope to share some new ‘nuggets’ of information.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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Scripting and The Autistic ‘Veil’

trainsThe nature of Autism is the brain’s desire to keep the world the same.  This is why one of the hallmark diagnostic features of Autism is repetitive, perseverative, and stereotypical behaviors.  One of the most common is scripting in which the child takes dialogue that he or she heard someone else say (usually a favorite cartoon or television character) and applies it in a repetitive and often nonfunctional fashion.   Scripting is often referred to as a Comfort Zone behavior.  This posting attempts to provide some strategies for how to deal with scripting as well as some reflections on the nature of Comfort Zone behaviors.

For children with Autism, the Comfort Zone is what the child will do when you let them do whatever they want to do.  Examples include: playing with/lining up cars, watching portions of the same video, flipping through familiar books, scripting, opening/closing doors/drawers, visually stimulating on an object (e.g., spinning), and staring off in the distance as if in a trance or daydream.  By the way, ever wonder why the fascination with trains?  The answer is that there is not likely anything much more linear and repetitive than a train going from one place to another and then back again.  I digress, so in this comfort zone, children are not connected or engaged with the world.  In fact, by the time kindergarten starts, one measure of school readiness is that the children are connected with the social environment most of the time and turn consistently to their names.  You probably notice that your child does not turn to his or her name being called consistently if they are absorbed in a particular activity.  If your child is ‘stuck’ inside their comfort zone and not paying attention to the environment, not easily engaged, not able to interact in a back-and-forth fashion; then they are going to need help leaving this comfort behavior for longer periods of time (i.e., you will need to engage them more and not allow them to be off on their own in a perseverative or repetitive behavior).  The key to remember here is that as engagement with others increases, perseverative/repetitive behaviors such as scripting decreases.  Thus, we must be aware of when the child is in his or her comfort zone and not allow them to remain there for too long.

I do want to take a moment to acknowledge, however, how it must feel for a parent to see the Autistic ‘veil’ drop in front of the child’s eyes as they check out from the real world for a moment and become absorbed in a repetitive behavior.  Especially for parents who have been working with their child for a number of months or years and have begun to see progress; the child’s return into scripting and other stereotypical behaviors is a glaring reminder that the child has Autism.  It also serves as a reminder to the world that something is not quite connecting in the child’s brain.  I often conceptualize this as a neurological tug-of-war that is taking place inside the child’s brain.  The hardwiring of the Autistic brain is determined to keep the world simple and the same, with little (if any) interest in relationships or social connections.   However, as the child makes progress and begins to learn how much fun can be had with others and the value of having play partners, another part of the brain begins to compete for dominance.

I see a similar phenomenon take place among children with OCD that I treat.  They experience what I refer to as “brain hiccups” that play tricks in one’s mind, often convincing the child that unless he washes his hands 15 times in a specific fashion, for example, something awful will certainly happen.  This thought will not go away (hence the ‘hiccup’) until the child engages in the ritual of the brain’s liking.  What these children describe to me, however, is the rational part of their brain telling them that they don’t really want to have to wash their hands that many times (or at all for that matter) to make the thoughts go away.  There are often strong similarities between the brains of children with OCD and brains of children with Autism.  However, one critical difference is that the OCD brain ultimately wants the repetitive thought to go away while the Autistic brain is comforted by the repetitive and familiar nature of the thought.

Remember:

  • The child in their comfort zone seems like they don’t want to be part of our world.  However, this is not regression or a lack of progress.  In fact…
  • Perseverative and stereotypical behaviors are not ‘bad’.  These behaviors help child regulate a chaotic world.
  • However, these behaviors may become habits & keep the child isolated.  These are potentially addictive for the child and need to be monitored.
  • ‘Joining’ in these behaviors helps our engagement with the child.
  • As our engagement with the child increases, the perseverative and repetitive behaviors naturally decrease!

For more information on this topic, visit the work of Dr. Rick Solomon and the PLAY Project.

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

Mark Bowers, Ph.D. © 2009

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Power School: Friend or Foe?

For those parents with a child attending a school with the Power School program, my opinion is mixed in terms of how ‘helpful’ it actually is.

Power School is a web-based student information system which recognizes the importance of connecting home with school.  Power School gives parents and students access to real-time information.

One website description states: According to “recent survey results”, parents use the web to become more involved in their children’s progress.  With Power School’s easy-to-use tools, parents can access secure student information online including: grades, assignment descriptions, school information, attendance and much more.

Each family receives a log-in and password to access their student’s progress and information at their convenience.

Sounds good in theory, right?  With only one or two parent-teacher conferences each year, having fast and frequent access to your child’s grades is a welcome option.  And while we worry about how much access to information our children have online, we are quick to log in and ‘see’ how things are progressing in the classroom.  After all, our kids usually answer the “How was your day?” question with “Fine.” and “Do you have any homework?” with “No.”  What’s the harm in checking in to see what is really happening at school?

I completely understand the intended purpose of Power School and think that it provides a valuable tool to many families.  However, I also see a variety of problems with the system.

  • Depending on your child, you may be more likely to check Power School (PS) on a consistent basis.  Indeed, kids who want their parents to back off and not check PS so much are often the same kids who behave in a manner that drives their parents to check in so much.  For example, a bright middle school student has difficulties organizing his work and often misses assignments or forgets to hand in his work.  As a result, his teachers enter zeros into various columns of PS and his current grade is listed as a “D” or “F.”  Logging in and seeing this grade and “missed assignment” in red ink is not going to get mom or dad to stop checking anytime soon.
  • In fact, Power School actually reinforces a parent to check when the information is negative such as missed work.  Parents who log in to see that all work is handed in and the child’s grades are A’s and B’s is less likely to see a need to consistently check.
  • Power School generally turns parents into an anxious mess.  The system has its flaws, especially the fact that timing issues can often cause a reaction about a missed assignment that your child may have handed in between the time you logged in and the time the assignment was added into the system.  This way, when you are confronting your child about the missed work, he or she is trying to convince you that it has been handed in, and you can’t trust this.  Some teachers are quicker than others when it comes to updating work completed.

I acknowledge that Power School can be an effective tool, especially if you need to review attendance and tardy history.  Further, there may be isolated moments of grade or homework completion confusion that can be easily clarified with a quick log in.

For families dealing with a child who is having difficulties with planning, organization, and assignment/homework completion I suggest considering the following:

For Middle School Children:

Establish a Homework Schedule-The child knowing when homework will be completed each day is helpful.  Allowing a fun activity to serve as a reward upon completion makes the hard work worthwhile.  Setting a block of time each night based on general amount of homework prevents the child from rushing.  For example, you set a one hour block for homework each night because your child generally has 30 minutes of work.  If your child finishes work quickly, they can read a book or review their homework until the hour is over.  This way, they understand there is no rush to complete work…the fun activity will have to wait regardless.

Don’t Hover Over Your Child During Homework-This is called ‘helicopter parenting.’  This is the same reason why many of the new generation of college students’ parents are calling professors on campus to complain about their child’s grades or the unfairness of a test.  Where does your child’s problem-solving and independence come from when you are always there to micromanage, review, check, correct, and battle with teachers?  If I had called my parents to complain about a bad test grade, their response would have been “work harder!’ not “Give me that teacher’s number, I’m gonna give them a piece of my mind!”

If You Must Check your Child’s Work-Be sure to note the correct items first.  Too often, we zone in on the errors and don’t focus on what the child is doing well.  Keep their confidence up whenever possible, especially during this age!

For High School Children:

Encourage Your Child to Check Power School on his/her own and then also establish a time you will log on (preferably with them) to review progress.  This way, your child knows when assignments must be turned in and can coordinate with teachers to have the information updated on Power School prior to parental review (another important step on the road to independence-advocating for oneself and problem-solving with adults other than parents!).  I usually recommend parents review Power School every other Wednesday of the month.  Weekends need to be enjoyable and logging on to potentially see bad news is a bad idea.  The middle of the week gives the child enough time in the beginning of the week to catch up and enough time at the end of the week to make up work.

Back Off! If your child does not have any learning difficulties or associated concerns that would require more support and intervention, then your best approach is to let your child handle school difficulties on their own while you focus on responsibilities and rules of the home such as curfew, cell phone/electronics use, etc.  If after a decent period of time (i.e., one quarter), your child continues to struggle in school then a professional consult may be warranted to rule out learning or emotional contributions to the sustained difficulties in school.

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Video Game Addiction

Doh!

Many of the families I see at The Ann Arbor Center for Developmental and Behavioral Pediatrics have at least one child who occupies most of their time with a video game system.  While many ‘tweens’ and adolescents enjoy video games, I see many children who have diagnoses of Asperger’s Syndrome and Pervasive Developmental Delay-Not Otherwise Specified (PDD-NOS) whose interest in this electronic media stretches beyond simple enjoyment.  Especially during the junior high and teen years when children are feeling more socially isolated or have preexisting social skills difficulties that make interpersonal interactions uncomfortable; video games provide an escape.

The American Academy of Pediatrics (AAP) guidelines recommend that parents limit a child’s “screen time” (includes video games, computer, television) to one to two hours per day at most.  An alternative that I often recommend to my families is to limit screen time to one hour on school nights and two to three hours a day on weekends and holidays.  My intention is not to make the child’s life miserable (which they often accuse me of trying to do!) but rather to open up opportunities for relationships.  Notice I recommend that parents limit, not eliminate video games.  Video games are not interactive between people.  Even if your child plays with a friend in the same room or online, this is not a spontaneous and reciprocal social interaction.  Indeed, if you turned off the video game and asked the two kids in the room to get a conversation going for more than a few minutes, they would inevitably become uncomfortable and want to discuss or return to playing the video game.

In the world of autism spectrum, professionals like myself are always concerned about Comfort Zone activities.   An autistic child’s Comfort Zone is his neuropsychological sense of comfort that occurs when he is doing what he wants and likes to do, especially when he is repeating activities.  The comfort zone is based on the child’s atypical neurological system that makes the child want to keep the world the same.  Thus, Comfort Zone activities for the young child may begin as lining up toys, progress to obsession with trains, and then morph into video game addiction during the teen years.

Although the strategies for how to wean a child from excessive video game usage vary from family to family, a few bits of advice may provide a good start:

  • Make conversation a priority in you home.
  • Read to your children.
  • Don’t use video games as a reward or punishment.
  • Encourage active recreation.
  • Get the TV sets and video game systems out of your children’s bedrooms.

Children who excessively play video games tend to do so for a reason.   Whether it is loneliness, social skills difficulties, feelings of isolation, anxiety, or depression; the use of video games becomes self-medicating and a means to quickly pass the time.  The strategies mentioned above are only a drop in the bucket if your child is experiencing difficulties in any of the areas just mentioned.  If you are fortunate enough to be reading this article while your child is still young, the best form of intervention is prevention.  So start early and set those limits now while encouraging more appropriate use of your child’s time.  Get them involved in fun activities out of the home to keep them interested and active.  If your child is already hooked into the video games for an excessive amount of time, it may be worthwhile to seek a professional consultation to begin breaking the so-called video game “addiction.”

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Autism Rates on the Rise?

Chances are, if you are reading this blog, you have heard about the new Autism prevalence study that was just published in Pediatrics earlier this week.  If you haven’t heard, a recent study found that the prevalence of parent-reported rates of autism was higher than previous estimates. Specifically, they found that 1.1% of all children ages 3 to 17 had autism (1 in 91) as compared to previous estimates of approximately 1 in 150.

Whether or not these new numbers are truly representative of a increase in the rates of diagnosis, autism is an epidemic.   The previous numbers of 1 in 150 births were evidently staggering enough that the Obama administration stepped in to help.  President Obama has made autism a priority from the first days of his presidency.  Less than a week after he was sworn in, The Department of Health and Human Services’ Interagency Autism Coordinating Committee released its first-ever strategic plan for government autism research. President Obama has backed this plan by adding $1 billion to his budget for autism over the next eight years.  Altogether, the federal government will provide nearly twice as much funding for autism research in the upcoming fiscal year as we had just three years ago.

On the genetic front, new genes and genomic regions that might be associated with autism have been identified by an international research team.

The researchers identified a single-letter change on chromosome 5 near a gene called semaphorin 5A, which is believed to help guide the growth of neurons and their long progressions, called axons. The activity of this gene appears to be reduced in the brains of people with autism.

The scientists also found a possible link between autism and parts of chromosomes 6 and 20.

In other news regarding the origin of autism, The Drexel School of Public Health will use a $14M NIH grant to establish a network of research sites nationwide that will study possible risk factors and biological indicators for ASD during the prenatal, neonatal and early postnatal periods. The researchers aim to follow 1,200 mothers of children with autism at the start of a new pregnancy and document the development of the newborn through 36 months of age.

In response to the new study of autism prevalence, Bob Wright, co-founder of Autism Speaks stated, “These new numbers should serve as a renewed call to action to take on what is clearly a major public health crisis not only in this country, but around the world.  People with autism are still not getting the therapies they need and adequate medical care for the medical conditions often associated with this disorder. And our society has yet to come to grips with the fact that this growing population of children with autism will become adults with autism who require a lifetime of services and support. We must act now to address these short and long-term challenges.”

We are attempting to address the treatment concerns of the growing population of children diagnosed with autism at the Ann Arbor Center for Developmental & Behavioral Pediatrics.  My colleague, Rick Solomon, M.D. has been awarded a $1.85 million grant from the National Institute for Mental Health (NIMH) that will fund a randomized, controlled study of The P.L.A.Y. Project intervention for autism.  We are now another step closer to our goal of addressing the national need for play-based intensive autism services.  You can read more about this exciting news here.

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The Anxious Child

All children experience anxiety.   Anxiety in children is expected and normal at specific times in development.  For example, from approximately eight months of age through the preschool years, healthy youngsters may show intense distress (anxiety) at times of separation from their parents or other persons with whom they are close.  Young children may have short-lived fears, (such as fear of the dark, storms, animals, or strangers).  If anxieties become severe and begin to interfere with the daily activities of childhood (such as separating from parents, attending school and making friends), parents should consider seeking the evaluation and advice of a child psychologist.

One type of anxiety that may need treatment is called separation anxiety. This includes:

  • constant thoughts and fears about safety of self and parents
  • refusing to go to school
  • frequent stomachaches and other physical complaints
  • extreme worries about sleeping away from home
  • overly clingy
  • panic or tantrums at times of separation from parents
  • trouble sleeping or nightmares

Another type of anxiety (phobia) is when a child is afraid of specific things such as dogs, insects, or needles and these fears cause significant distress (i.e., more than what would be expected for a child of the same age).

Some anxious children are afraid to meet or talk to new people.  Children with this difficulty may have few friends outside the family.

Other children with severe anxiety may have:

  • many worries about things before they happen
  • constant worries or concern about school performance, friends, or sports
  • repetitive thoughts or actions (obsessions)
  • fears of embarrassment or making mistakes
  • low self-esteem

Anxious children are often overly tense or uptight.   Some may seek a lot of reassurance, and their worries may interfere with activities. Because anxious children may also be quiet, compliant and eager to please, their difficulties may be missed. Parents should be alert to the signs of anxiety so they can intervene early to prevent complications.  It is important not to discount a child’s fears.

If you are concerned that your child has difficulty with anxiety you should consult a child psychologist or other qualified mental health professional.  Severe anxiety problems in children can be treated.  Early treatment can prevent future difficulties, such as loss of friendships, failure to reach social and academic potential, and feelings of low self-esteem.  Treatments may include one or a combination of the following: individual psychotherapy, family therapy, behavioral treatments, medications, and consultation with the school.

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To Spank or Not To Spank…

A paper presented at the International Conference on Violence, Abuse and Trauma on Sept. 25 by sociologist  Murray Straus has caught my attention this week.  Straus and his colleague Mallie Paschall followed children over the course of four years and determined that those who were spanked had up to a 5-point lower IQ than their peers who were not spanked.  Further, the more the children were spanked, the lower their IQs.

This debate is not new.  In fact, I find myself in this debate at least a few times each month with some of the families I see.  The age old question is whether or not spanking is an effective form of discipline.  My professional stance (in conjunction with the science that supports it) is that spanking is actually punishment (not discipline) and is only effective in the short-term.  Try telling that to the ‘old school’ father who swears, “It worked on me when my father spanked me!”  With a little more investigation in my office, I am often able to reveal that while it may have garnered attention in the short-term, it fueled resentment toward the parent over the long-term.

I truly believe that the majority of spanking occurs in the form of a parental temper tantrum in which the parent has lost control and is at a loss for an effective discipline strategy.  There are a number of problems with punishment that I encourage parents to consider when deciding if they really want to employ spanking as a method of punishment.

  • Spanking focuses anger on the parent doing the spanking.  When we resort to punishment it gives children someone else to be mad at or something else (the spanking) to blame.
  • Spanking causes the behavior to stop quickly, but in the absence of spanking, the negative behavior returns.
  • Spanking does not teach accountability. The “punisher” (parent) is responsible to see that the child’s behavior changes.   The child learns nothing on their own as a result of the spanking.
  • Punishment denies a child the right to experience the real consequence of their actions.  If your child hurts someone else, for example, the other child may not want to play with your child anymore.  Your child quickly forgets this possibility when spanking is introduced.
  • A big error comes when we think that the punishment has taught the child what to do the next time a similar situation occurs. It has taught the child NOT to do something… but it has not taught them what they should do!

In case those reasons were not enough, we also know that spanking makes children anxious (especially toward the parent using this method) and spanking can lower self-esteem.  A report endorsed by the American Academy of Pediatrics in 2008 looked at 100 years of research and concluded, “There is substantial research evidence that physical punishment makes it more, not less, likely that children will be defiant and aggressive in the future.”

The full report can be read at www.phoenixchildrens.com/discipline

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